tag:blogger.com,1999:blog-177548332017-07-19T01:50:21.822-05:00Why am I still here?Read all about the amazing adventures of a wet-behind-the-ears doctor, using the immature defense mechanisms to talk herself through residencyTiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.comBlogger367125tag:blogger.com,1999:blog-17754833.post-26179636591330548212009-06-23T17:51:00.003-05:002009-06-23T19:14:03.122-05:00ChangesToday, I drove home from work post-call, crying. I had a busy, largely sleepless night, with the lovely addition of the onset of a head cold. I made it through the call shift, made it through my work shift in the morning, then headed to a feedback session with one of my course directors. The course was "Empathy" and involved interns listening to comments made by patients on tape, then delivering empathic responses back.<br /><br />Most of us had a hard time with this.<br /><br />One intern said she felt like she couldn't respond to the happy patient because she only sees suffering or she assumes the patient is manic or borderline--she didn't know how to treat someone who was just happy. My responses felt to me like I was still using them as questions to extract more information, instead of just interjections to let the patient know I was listening and perceiving what they said.<br /><br />My course director said I had done a good job, and that I had "a practical, pragmatic approach" that she felt would become less self-conscious and improve over time. I started to say something in response and instead tears welled up (I've cried in front of her before, so I doubt she was shocked).<br /><br />I told her I felt like I used to be better at empathy, at understanding where patients come from and what they're going through, and trying to connect, and that I've lost something this year. That I used to enjoy trying to connect with patients, and now I find it difficult (I didn't tell her that often, I don't bother trying).<br /><br />As I drove home, I started to cry again. At first, I couldn't tell what was bothering me. I assumed it was tiredness + being sick. It felt too bad to be that simple, though. When I get really upset, I feel a squeezing pressure in my chest that seems to wring tears from me (yes, I'm aware this is psychosomatic). I tried to think, what was bothering me? Then I realized I was still crying over what I'd lost this year. But why am I so burned out, empty? What have I lost?<br /><br />I think a combination of forces has dried up my empathy well (maybe it wasn't very deep to begin with?). Call it soul, or humanity, or empathy, or sympathy, or "being with"--whatever--I feel like mine has shriveled a little (or a lot) under the blaze of a ferocious burn out.<br /><br />(A note about burn out: when high school seniors, or college seniors moan about being "so burned out on school right now", that is not the same. This kind of burn out leaves you feeling hollow and empty. It invades your personal life, your marriage, your quiet time, and your dreams, even when not at work.)<br /><br />I'll point a finger at chronic sleep deprivation. I've been working around 60-65 hours per week (which is not that much, really, by medicine standards; please, surgeons, don't hit me) and taking 5-6 calls per month for the past 6 months. I don't feel recharged between calls, and I think over time my reserves have gotten lower. I've taken some vacation time and tried to catch up, but it seems to only take one call to flatten me out again (I like my sleep, so sue me).<br /><br />That's not the whole story, though. Part of it is the patient population I treat. On call, the most memorable patients are the substance-using (usually cocaine or alcohol) homeless narcissists (or antisocials) who are in it to get a free bed. I used to fight this, but I've given in to the system where I work. This system pulls these patients in and suckles them for a while. Aww, did you relapse for the 40th time? Was that placement not nice enough for you? You didn't make any of your follow up appointments (often, despite having benefits, bus passes, or special transportation) and couldn't be bothered to take your meds (given out for free), but that's okay, come here baby, I have a bed and a tray for you. I strongly feel that this system thereby encourages these patients to continue this behavior. There's no need to make choices or take responsibility when there's always a cushy safety net. Just say the magic words ("I'm thinking about hurting myself", but don't have a real plan) and you're in. I don't mean to suggest that all my patients are like this, but enough of them are (and they all seem to come in crisis at 3 am, because they know an intern is on, rather than during the day when the attending will send them to outpatient rehab) to be grating. I said in a previous post that there are few true psych emergencies at 3 am, and I still hold that to be true. There are some, and I'm happy to treat those, but most 3 am consults to the ER are for someone who's crashed off cocaine, feeling suicidal, and completely oblivious to the idea that cocaine could make them feel this bad. They want me to fix their sadness, but don't want to give up the high.<br /><br />Some few of these patients can be verbally abusive, which makes it oh-so-exciting when I get to call the police or security to escort them out.<br /><br />I hate the stigma against the mentally ill, even though I recognize some of it within myself. I recently treated a patient with delirium tremens who had a <a href="http://images2.clinicaltools.com/images/pdf/ciwa-ar.pdf">CIWA</a> of 21 on my exam. The reason for consult was "rule out other psychiatric issues". My note politely stated that I would reassess other psych issues after pt was more alert and oriented (not <a href="http://www.all-acronyms.com/A&amp;O+X3/alert_and_oriented_to_person,_place_and_time/1073600">A&amp;O</a> x none like on my exam) and that the primary team should consider increasing the lorazepam drip. Agitated patients who cannot give a clear history of alcohol or benzo use are often shuttled to psych while having withdrawal. I've seen patients not receive appropriate treatment of surgical or medical conditions with no other explanation than "due to psych diagnosis". (I also hate inappropriate medicine consults by psych because someone forgot how to look up the dose on a blood pressure med, so I'm perfectly aware that this is a two-way street).<br /><br />Of course, when I went to the dentist last week and saw that my chart said (in Magic Marker on the front cover) "depression, nervousness, psych problems", I nearly cried in the dentist's office. I mentioned having a history of depression and anxiety during my intake, but I had no idea it would be proclaimed on the front cover of my chart like that, for all the office staff to see. So I understood my patient last night who told me she had lied to her psychiatrist about her previous suicide attempts because she was too ashamed, so she said she'd never done anything.<br /><br />I believe a lot of my burn out is related to having been an intern for nearly a full year. Internship and residency are tough (yes, even in psych). I also believe that I would be pretty burned out no matter which specialty I'd chosen.<br /><br />But a part of this burn out is psych itself. It's the overuse of meds, the overuse of diagnoses, the stigma against psych patients and psych doctors (but man, are you glad to see us when you need us!), the massive pharma scandals (Seroquel, Zyprexa, and Abilify all come to mind), the overmedication of children who need appropriate discipline (and the recent revelation that the data supporting stimulant use was oversold to us), and the overwhelming feeling that I'm not cut out for this like I thought I was. I'm not as good at psych as I thought I could be, which is tough for me, as I'm usually good at clinical work (for pete's sake, I won an award for best clinician of my med school class when I graduated!). I doubt I'd be a terribly skilled therapist, and I believe that therapists <span style="font-style: italic;">should</span> be skilled. I have some sensitivity to what people are feeling and am able to read between their words, but I'm finding that doesn't seem to be enough. In other words, I'd probably be a competent psychiatrist, but not an excellent one, and that's not good enough for me.<br /><br />So for all these reasons, and one other big one (and maybe a few I forgot), I'm switching residencies to internal medicine. The other big one, obviously, is that I like medicine and miss it. I think I'd be pretty burned out right now if I'd just finished a year of medicine internship, so I'm trying to think pretty realistically (although sometimes I'm so desperate to escape my burn out that I get "grass is greener" syndrome and wish for medicine to fix my problem). I wasn't a fan of medicine as a med student, largely due to a certain attending who tore me a new one and then said I should go into medicine (which is a dumb reason to avoid a whole field, really). I clicked with medicine as an intern, though. I was good at it. I was my usual gets-too-flustered-when-paged, <a href="http://en.wikipedia.org/wiki/Obsessive-compulsive_personality_disorder">OCPD</a>-I-might-have-missed-something self on medicine just like on psych, but I was better there. I was better able to see the big picture on medicine than I remembered, and less able to see the big picture in psych than I thought.<br /><br />So there, that's my big announcement. Will switching residencies solve everything, or anything at all? Maybe not. It's not that I hate psych, because I don't, despite all the mean things I just said about her. After all, you have to care about something to get angry about it. There's nothing magical about doing internal medicine now (and many of the same problems exist there as well); I still don't know exactly what my career will look like from here (which makes me nervous), but I realized at some point in the fall that I could no longer see myself as a psychiatrist, and in November I realized I could see myself as an inpatient medicine attending, or supervising residents in a clinic, giving lectures to med students--in short, similar plans to what I had for psych, only now in medicine. I'm doing psych consults this month, which is giving me some closure (which I needed). I'll miss psych, especially during the sweet 3rd and 4th years of psych residency when they work 8-5 M-F and I'll be a ward upper level on medicine. I'll miss the intern class I came in with--they're wonderful people, and it has been a pleasure to watch them learn how to be doctors. The psych department is full of people who are special to me and I will miss them.<br /><br />Fortunately, I'm staying within the same medical college, so the switch is relatively painless. I'll be a PGY-1.5 for 6 months, then start PGY-2 in January. This will put me 6 months behind for medicine, but 6 months ahead for psych. I still plan on doing a fellowship, so I'll be a trainee for a long time ahead.<br /><br />I've thought about combining medicine and psych, and I think that's a definite possibility. I could run a primary care clinic for psych patients, for example. My psych program has offered to let me come back in the future if I want to do so; I haven't ruled this out (although I do NOT want to be a trainee for the rest of my life).<br /><br />So now, on to different things. As of next Wednesday, I will no longer be a Tiny Shrink. As I've already changed the handle on this blog a couple of times, I think I'm going to close the blog out and maybe start a new one. If I do that, I'll post a link. As I struggle to find my identity as a doctor, I'm not sure it's fair to make my blog struggle with me. It's kind of like <a href="http://en.wikipedia.org/wiki/Crime_Scene_Investigation#Main_Characters">CSI</a> picking a new lead actor when Gil Grissom's character left (or maybe not). So I think this is goodbye for now. I really appreciate anyone who has read this blog or left a comment (or indeed, made it to the bottom of this circumstantial, rambling mess of a post), and I thank you.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com17tag:blogger.com,1999:blog-17754833.post-24648535866989843392009-06-16T21:32:00.002-05:002009-06-16T21:42:04.096-05:00Natural Does Not Equal Healthyhttp://www.cnn.com/2009/HEALTH/06/16/zicam.fda.warning/index.html<br /><br />In brief, 3 of the nasally-applied Zicam products (which are sold as supplements, and therefore not regulated by the FDA) may be causing people to lose their sense of smell. The FDA has urged patients to stop taking the products, and has notified the manufacturer that they will not be allowed to market these products without FDA approval.<br /><br />My favorite part of this article:<br /><br /><blockquote>On its Web site, however, Matrixx says the allegations are "unfounded and misleading."<p> The company contends that "there is no known causal link between the use of Zicam Cold Remedy nasal gel and impairment of smell. No well-controlled scientific study has demonstrated a potential cause-and-effect relationship between the use of Zicam and diminished smell function. No court cases have revealed any reliable evidence of any causal relationship."</p></blockquote><p> Well, whaddaya know! They know how to play ball! They may not have to do "well-controlled scientific [studies]" to prove that their homeopathic product works, but they want the FDA to produce one to prove it hurts people!<br /></p><p>Does Zicam cause anosmia? I have no idea. Matrixx is correct that there is no current proof of a causal relationship. However, if we regulated these supplementary products, at least for safety if not for efficacy, then we'd likely know the answer to this question. Not that it matters, as I've never used the stuff, but as I like to be able to stop and smell the roses (or at least my gardenias), then I will probably avoid Zicam--just to be safe. One fewer day of cold symptoms or a lifetime of not being able to enjoy eating as much... not much of a choice, in my book.<br /></p>Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com1tag:blogger.com,1999:blog-17754833.post-66433334508123686132009-05-14T21:58:00.001-05:002009-05-14T22:00:52.729-05:00Vacation Part IITaking 3 days off to go see my dad and my grandmother. Trying to catch up on my sleep before taking more calls.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com1tag:blogger.com,1999:blog-17754833.post-65779764355563319302009-05-10T20:24:00.001-05:002009-05-10T20:24:36.659-05:00Weight Watchers<div>The other day, I took off a few hours in the afternoon and went to the gym (then came back to work so the other intern could leave early). I was super proud of myself--look at me, I&#39;m being so healthy! I knew my pants were fitting a little tight, but I used the usual lie (they must have shrunk in the wash) and blew it off. </div> <div> </div> <div>Until I got to the gym and weighed in.</div> <div> </div> <div>I was only 1-2 lbs underneath what I&#39;d set as my &quot;maximum&quot; weight. A weight I&#39;d said &quot;I&#39;ll join Weight Watchers if I get to that point.&quot; While this is only a few lbs above where I&#39;d been a few months ago, it has definitely been creeping upwards. This scared the junk out of me. Often times, I&#39;ll see people walking around who are very obese and I&#39;ll think &quot;I never want to look like that&quot;. I&#39;m well aware that nobody becomes morbidly obese overnight, though; it happens 1-2 lbs at a time, which is why I set a ceiling for myself. Now, I&#39;m almost at that ceiling, and I&#39;ve decided not to wait.</div> <div> </div> <div>So, I enrolled in WW online.</div> <div> </div> <div>My first few days have been very frustrating. I&#39;ve been trying to use the online tracker to enter in my foods, and have been totally astonished how many calories I&#39;ve been eating. My denial voice keeps saying &quot;I usually eat okay...&quot; but the sad truth is that obviously, I don&#39;t. In 4 days of entering points, I was something like 17 points behind FOR THE WEEK. AFTER ADDING IN MY WORKOUTS AND GARDENING AND DIGGING HOLES FOR TREES. This is a huge wake up call for me, but I&#39;m left going, what do I do? How do I start menu-planning, when I&#39;m frequently on call and at the mercy of the hospital or eating drug-rep food or eating indulgently because I&#39;m on call? I have so many excuses, some good and some not, but it&#39;s hard to get started. </div> <div> </div> <div>My goal is not to lose tons of weight. I could stand to lose 25-30 lbs to really be in the healthy range, but I just don&#39;t think I&#39;m ready to do that. Right now, I want to lose 10-15 lbs and be healthier, more aware of what I&#39;m eating. Especially since I do want to have children in a few years, I want to be as healthy as possible before trying to conceive. I also want to pass healthy eating habits on to my children (and I&#39;d be appalled if they ate how I eat now).</div> <div> </div> <div>But sometimes this seems like an insurmountable task, and I&#39;m standing at the very beginning of this--I can&#39;t see very far ahead. I have no idea if I&#39;ll make it or not. I don&#39;t have a really fixed goal, either--but maybe that&#39;s a good thing, because if I just thought &quot;I&#39;ll lose these 10 lbs and be done&quot; then I&#39;d probably relapse. Who knows how this will go, because I don&#39;t.</div> Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com9tag:blogger.com,1999:blog-17754833.post-41925955669675713652009-05-03T17:20:00.010-05:002009-05-03T17:33:35.696-05:00The Key to Mental Health<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://3.bp.blogspot.com/_2iDBnUocKKI/Sf4ZudDh_MI/AAAAAAAACCQ/Ki-gsb6J1o0/s1600-h/DSC04318.JPG"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 240px;" src="http://3.bp.blogspot.com/_2iDBnUocKKI/Sf4ZudDh_MI/AAAAAAAACCQ/Ki-gsb6J1o0/s320/DSC04318.JPG" alt="" id="BLOGGER_PHOTO_ID_5331727294717361346" border="0" /></a>I've decided that the one of the best ways to be mentally healthy is to garden. By this I mean I'm tired, cranky, burned out, and counting down my remaining calls, but when I drive home, I get out of my car, go into my yard, and just smile. I keep buying more and more plants to plant because it just makes me happy to putz around in the dirt. Yes, my ancestors were farmers, but I've never felt like I was particularly good at growing things until recently. My flowers are blooming, my trees are finally upright and that lovely dark green, and my herbs are tasty (I bought <a href="http://www.amazon.com/AeroGarden-9105-00Z-Serve-Vinaigrette-Marinade/dp/B0015MM3KC">this</a> the other day and it is AWESOME).<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_2iDBnUocKKI/Sf4aASIg58I/AAAAAAAACCY/yrbF8ux8ti4/s1600-h/DSC04315.JPG"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 240px;" src="http://2.bp.blogspot.com/_2iDBnUocKKI/Sf4aASIg58I/AAAAAAAACCY/yrbF8ux8ti4/s320/DSC04315.JPG" alt="" id="BLOGGER_PHOTO_ID_5331727601023117250" border="0" /></a>I'll be making an announcement at some point on here, but I haven't decided how I'm going to do it yet. No, I'm not pregnant, nor did I get pregnant and sneak off to give birth, nor did I adopt a Malawian baby. For now, I'm just going to put up some pictures of my plants:<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://3.bp.blogspot.com/_2iDBnUocKKI/Sf4bPgxI6BI/AAAAAAAACDI/72uIy2kkAB8/s1600-h/DSC04314.JPG"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 240px;" src="http://3.bp.blogspot.com/_2iDBnUocKKI/Sf4bPgxI6BI/AAAAAAAACDI/72uIy2kkAB8/s320/DSC04314.JPG" alt="" id="BLOGGER_PHOTO_ID_5331728962161272850" border="0" /></a><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_2iDBnUocKKI/Sf4ao3eWYKI/AAAAAAAACCw/TnbAVYQtWpU/s1600-h/DSC04323.JPG"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 240px; height: 320px;" src="http://2.bp.blogspot.com/_2iDBnUocKKI/Sf4ao3eWYKI/AAAAAAAACCw/TnbAVYQtWpU/s320/DSC04323.JPG" alt="" id="BLOGGER_PHOTO_ID_5331728298241581218" border="0" /></a><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/_2iDBnUocKKI/Sf4bdld2YWI/AAAAAAAACDQ/Qqq2npUiOgw/s1600-h/DSC04324.JPG"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 240px;" src="http://1.bp.blogspot.com/_2iDBnUocKKI/Sf4bdld2YWI/AAAAAAAACDQ/Qqq2npUiOgw/s320/DSC04324.JPG" alt="" id="BLOGGER_PHOTO_ID_5331729203940712802" border="0" /></a><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_2iDBnUocKKI/Sf4a1WG4DtI/AAAAAAAACC4/lPGA81C2HJo/s1600-h/DSC04310.JPG"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 240px;" src="http://2.bp.blogspot.com/_2iDBnUocKKI/Sf4a1WG4DtI/AAAAAAAACC4/lPGA81C2HJo/s320/DSC04310.JPG" alt="" id="BLOGGER_PHOTO_ID_5331728512623054546" border="0" /></a>Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com4tag:blogger.com,1999:blog-17754833.post-53850506011790447682009-04-12T16:04:00.001-05:002009-04-12T16:04:49.372-05:00FREE=MORE (Some Random Thoughts)<div>I&#39;m borrowing a line from the Happy Hospitalist because I really appreciated one of his posts today. Go check it out here: <a href="http://thehappyhospitalist.blogspot.com/2009/04/land-of-screwed.html">http://thehappyhospitalist.blogspot.com/2009/04/land-of-screwed.html</a>. I know not everyone is a huge fan of Dr. Happy, and I don&#39;t always agree with him myself (and sometimes when I do agree with him his tone still kind of gets to me), but still, I think the majority of this post is spot on. </div> <div> </div> <div>We are facing a time in this country (and in some other countries as well) where we are going to face more rationing of care. I say more rationing because we already have some rationing in place. Every time an insurance company, Medicare, or Medicaid chooses not to pay for a claim, that&#39;s rationing. Currently, our system of rationing is haphazard and doesn&#39;t make much sense. 1) If you have money, you can pay for any test you want. CT scan of the heart to check for coronary artery disease? Sure! That&#39;ll be $500 up front. 2) Some insurance plans pay for tests that others don&#39;t, and it may have more to do with the negotiations between the insurance company and the hospital than whether the test is necessary or how much it costs. 3) Medicare benefits are not even across the country; recipients in one state may be able to get a test that those in the next state over can&#39;t. 4) Medicaid benefits are even more uneven, negotiated by each state. 5) The uninsured receive wildly variable care. If they have cash (the self-employed uninsured) they may receive care. If they go to the county hospital, they may receive care. It varies widely, and they may not be paying anything for it. </div> <div> </div> <div>I think many people are afraid that &quot;rationed care&quot; is going to apply to them, personally. </div> <div> </div> <div>Many people with insurance are afraid their care is going to be different, and that they will get less. We expect our MRI&#39;s and our expensive back surgeries and our brand name drugs. We expect these things because they&#39;re flashy and we&#39;re taught they&#39;re the best. We resist when we hear they&#39;re not the best. PSA testing may not be effective, but by gum I want to know! I think we&#39;re basically a nation of hypochondriacs, using our healthcare system to ease our anxieties. </div> <div> </div> <div>And then some of the medical interventions that really make a long-standing difference--for example, vaccinations, exercise, psychotherapy--get ignored, downplayed, vilified, or are not covered by insurance. We want the quick fix. I was asked by a highly intelligent patient (in seriousness) whether I had a pill that would make him happy. He didn&#39;t want the medicine &quot;that didn&#39;t make me unhappy but didn&#39;t make me happy&quot;. </div> <div> </div> <div>Everyone is afraid of the long lines we hear about in Europe and Canada. Many of the situations I&#39;ve heard about, though, requiring months of waiting, are for elective procedures. We want our knee replacements NOW. My back hurts NOW. Never mind that herniated disks may or may not be the cause of that pain, it was on my MRI and I want my picture to be prettier NOW. </div> <div> </div> <div>I don&#39;t think there&#39;s a single best answer out there; I think all the sides have some truth to them. Patients demand certain things that they shouldn&#39;t; doctors prescribe and order willy-nilly because someone else is paying; insurance companies deny legitimate claims to pad their bottom line; government care is fraught with its own perils and problems. </div> <div> </div> <div>I have to agree with Dr. Happy, though, on one thing: when we removed the payment from the doctor-patient relationship, we added a whole new world of problems. &quot;Insurance&quot; should mean a policy to save for a rainy day. I don&#39;t call my car&#39;s insurer when I need an oil change or routine maintenance; I don&#39;t call my homeowner&#39;s company when my house needs to be vacuumed or the lawn mowed; so why do we expect our health insurer to pay for our checkups? We really shouldn&#39;t call it &quot;insurance&quot;. After all, there&#39;s no guarantee you&#39;ll get care just because you have insurance. Your claim could be denied for any number of small errors, and then you&#39;ll get the whole inflated, padded bill all to yourself. </div> <div> </div> <div>A healthcare policy for a group of employees, for example, tries to float the costs of the few unhealthy patients on the premiums of the rest of the healthy; the problem is that the healthy think &quot;$10 copay? I have the sniffles, I should go to the doctor.&quot; Or they think &quot;My knee hurts; I could take Advil, or I could get the MRI because the insurance is paying for it.&quot; The costs go up and up as people utilize more care (and more expensive care).</div> <div> </div> <div>I guess one of the biggest problems is that so much of the care is unecessary. Back surgeries don&#39;t necessarily reduce pain or return you to work. Penicillin for strep may not actually prevent rheumatic fever like we once thought. Cardiac stents don&#39;t necessarily work better than taking your aspirin and blood pressure medication, and we don&#39;t really have fewer bypass surgeries even though we&#39;re doing more stents. PSA testing doesn&#39;t save lives; ovarian cancer screening doesn&#39;t save lives; and even mammograms are suspect. Giving proton-pump inhibitors in the hospital to prevent rare occurrences of GI bleed may interfere with your Plavix and give you a heart attack. Getting the glucose down to normal in the ICU can kill you. If we truly analyze our diagnostic tests and our medical and surgical treatments according to strict evidence-based criteria, how many would stand up and how many would be no better than &quot;Take two aspirin and call me in the morning&quot;? How much of what we&#39;re spending our healthcare billions on is junk?</div> <div> </div> <div>I also think doctors share a large amount of this blame. If the public expects the MRI, it&#39;s probably because a doctor ordered it for their sister, or a doctor went on the local news station to advertise, etc. While I think public expectations need to be better managed, I also think our continuing medical education needs to be revamped. How easy would it be, out in private practice, to pick &quot;fluffy&quot; CME courses paid for by drug companies that come with a free steak, instead of intensive and expensive courses that require real learning? I also think we are not good stewards of the healthcare dollars we help manage. Every time I order a full CBC with differential, I could have saved a significant amount of money. Any time I might think &quot;I&#39;ll order this possibly useful test, they have insurance&quot;, I need to be swatted. </div> <div> </div> <div>Doctors and patients are more money-conscious than ever. Both groups are worried about money constantly. But we&#39;re not supposed to talk about it with each other. We placed the insurance companies in between us and then were surprised when our discourse became complicated because someone else was taking and making money off our interaction. Seemingly, the insurance companies are the only ones truly benefiting off this interaction, because certainly the doctors and the patients aren&#39;t.</div> <div> </div> <div>Perhaps we could go to some kind of &quot;basic care&quot; model, where our basic checkups and very basic labs are covered by a yearly fee (provided by the healthcare provider themselves), then we have a high deductible policy for true medical emergencies. Patients with long-standing chronic conditions that require the most medications, the most admissions, and the most cost, could be covered by the government; others could be allowed to purchase more care depending on what they think they&#39;d need. Have a kid with asthma? Get a plan with certain types of coverage or a lower deductible. Allow for interstate insurance policies, so that I can shop for insurance in Oregon if they have a better plan than that available to me. Allow for transparency in healthcare interactions: doctors should be able to publish the cost of their office visit on their website (and it should be roughly the same for all comers, whether insured or not; the doctor can then decide to discount if need be) as well as the price of the most commonly used tests. Let patients decide how much elective care they want to pay for, and require emergency coverage (or make it very affordable). </div> <div> </div> <div>Or do something else entirely, but (in the words of Kenan Thompson from <a href="http://www.nbc.com/Saturday_Night_Live/video/clips/update-thursday-part-2/742141/">SNL</a>) FIX IT!</div> Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com1tag:blogger.com,1999:blog-17754833.post-14192063630875790642009-04-08T20:02:00.002-05:002009-04-08T20:04:56.141-05:00Still HereJust haven't felt much like posting lately. Back soon. In the meantime, I'll be watching "<a href="http://www.fox.com/lietome/?src=home_page_whats_on_tonight">Lie to Me</a>", my new favorite show.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com0tag:blogger.com,1999:blog-17754833.post-53008877414416176472009-03-10T20:15:00.002-05:002009-03-10T20:24:54.174-05:00I Hate Daylight Savings TimeThis whole "spring forward" thing just plain sucks. Chronic sleep deprivation + post call + losing an hour of sleep had me very unhappy this weekend.<br /><br />Fortunately, the weather has been lovely, so we planted a tree and some azaleas this weekend. Now, I have new flowers, 2 new trees, a few herbs, and re-organized landscaping. There is something healing about planting something.<br /><br />I'm not a great example of how to keep yourself healthy during internship, but I do my best. I'm averaging 1 workout per week, which isn't great, but it's better than 0 workouts per week (baby steps, people, baby steps). I'm really trying to eat better, making overall healthy choices and not drinking sodas unless I'm on call. I planted some green things in the ground. We're hanging out with our neighbors more often. I actually sat down with a huge stack of NEJM's, JAMA's, and Green Journals a couple of weeks ago and skimmed/read them all (which also got them off my coffee table). We bought a Roomba, which is helping keep the cat hair at bay.<br /><br />If we could only invent a pill that instantly gave you all the sleep you were missing (without taking away the time to get all that sleep), I'd be set.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com3tag:blogger.com,1999:blog-17754833.post-85700239816295510852009-02-23T19:20:00.003-06:002009-02-23T20:14:52.271-06:00HomelessIn psychiatry, even more than in internal medicine, we treat a lot of patients who are currently or have been homeless. From work I used to do at a clinic for homeless patients, I'm aware that there are different "levels" if you will of homelessness. There are people who stay with family or friends, people who live in motels, people who sleep in their cars, people who live in shelters, and people who sleep on the street. Sometimes whole families are homeless, but most of my patients are single. There are people who are transiently homeless, and people who are chronically without a permanent place to stay. Many are "mentally ill", but this covers a very wide range of possible diagnoses. I've met some patients with chronic psychotic disorders, often untreated, who have no family to look out for them and were homeless. Many of my patients, though, have personality disorders (usually narcissistic, borderline, or antisocial) and/or are chronic drug and/or alcohol abusers.<br /><br />In psych, we refer to some of the last group as "having poor coping skills." In other words, they don't know how to be "grown-ups" as our culture and society mandates. Especially when substances are involved, their only method of coping with stressful situations may be to pop a pill or drink a bottle. They may come to psychiatric attention because of a suicide attempt or accidental overdose; sometimes they come to the emergency room voluntarily because they "feel suicidal" or "think I'm going to hurt someone". Patients in the latter group sometimes aren't admitted to the hospital, and are discharged back to the streets.<br /><br />I've noticed that I have a bias against this latter group. Even though psychiatrists (and other physicians) treat substance abuse, many of us seem to think of these disorders as non-psychiatric and non-medical for some reason. It's easier sometimes to make allowances for someone with bipolar or schizophrenia than for someone who's "just drunk" or "just high" or "just a borderline". I think part of it is because there is such a large volitional component to drug use, ie, no one MADE them do the drugs (we assume), whereas no one chooses schizophrenia (although schizophrenics may choose not to take their meds, or may choose to do drugs). It's true that there is a heritable component to addiction, and also true that many patients start using substances as young teenagers (13-14 years old) before they're able to fully appreciate the consequences of their actions.<br /><br />So why the bias? Why do I feel like I have a hard time treating these patients? (For that matter, I think many doctors have a hard time treating such patients). Part of it is the volition thing. Part of it is that there's a narcissism involved with substance abuse--people who are addicted care mostly about their addiction, and often (at least the ones who come to the psych ER) can be less than friendly. Some become outright abusive. Part of it is what some of these patients do to feed their habit--I've had some say they prostitute themselves, some who beg, and some who steal, and these are just the ones who talk about it. Some are on disability, which is frustrating to someone who works hard; why should they get their $3000 check per month and get to spend it all on crack?<br /><br />It would also be different if these patients were asking for help with their addiction when I see them. Instead, many of them seem to be saying "the right words" to get admitted to the psych hospital because it's cold outside, or raining, and have no intention of quitting their drug of choice. This irritates me. It's a hospital, not a free hotel. If I admit all of these patients, then there's no room for the acutely psychotic patients wandering off from home or the manic who hijacked a bus.<br /><br />One of my patients said something profound to me the other day. This person had been homeless in the past, and was facing discharge to the streets. The quote: "I've been homeless before, man, I've slept on the streets before. Man, when you're out there, it's like you're not a person anymore, it's like you're not a human being."<br /><br />So how to balance humanity with doing the right thing, which often means denying these patients admission? I'll be honest, this is hard for me. I find this emotional balance to be very tiring. I guess just like the paging etiquette thing, I just have to keep trying. I don't have an actual solution, at least not yet.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com2tag:blogger.com,1999:blog-17754833.post-62405375486482153672009-02-18T23:35:00.001-06:002009-02-18T23:35:57.390-06:00I'm a Big Kid Now!<div>There comes a time in every young doctor&#39;s life when they realize that they are now an adult. Eight years (in the US) beyond high school, the medical resident has put off true adulthood for perpetual studenthood for a long time, especially if they did not take time off and work or pursue an alternate career. For some residents, it&#39;s the time they put on the long white coat; it may be the first code attended, the first time they signed an order as &quot;X Y, MD&quot;; the first time a nurse asked &quot;What should we do, Doctor?&quot; All of these experiences have happened to me, and they made me feel a little bit grown-up, but this one really takes the cake. This one says I&#39;m really an adult and there is NO GOING BACK. This cat is out of the bag.</div> <div>&nbsp;</div> <div>Friends, I got a jury duty summons the other day, and I CAN NO LONGER JUST TELL THEM I&#39;M A STUDENT SO I DON&#39;T HAVE TO GO!</div> <div>&nbsp;</div> <div>So here soon, I will present myself to a court house and go through whatever jury duty entails. Somehow I doubt I&#39;ll actually get picked for anything, so I predict I&#39;ll show up and waste a lot of time and then get to go home $15 richer. Or, just my luck, I&#39;ll get seated for a really long trial and be sequestered in a motel surviving on bad sandwiches--it&#39;ll be just like a John Grisham novel, except half as exciting. </div> <div>&nbsp;</div> <div>Adulthood--not all it&#39;s cracked up to be? Although the shopping part is pretty fabulous, as well as being over the legal drinking age, and getting to do what I want to do... I guess you have to earn that part somehow, so jury duty, here I come!</div> Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com4tag:blogger.com,1999:blog-17754833.post-34010021261247643382009-02-17T20:03:00.002-06:002009-02-17T20:28:26.533-06:00Say What?[Homeless patient receiving disability payments from the government, angry with me for not admitting him to the hospital to protect him from homelessness]: "I pay your salary, did you know that?"<br /><br />[Sleepy, cranky me on call]: "...?"<br /><br />[Well-rested co-intern the next day, upon hearing the story]: "Actually, my tax dollars pay for your health care AND my salary."<br /><br />_________________________________________<br /><br />More Truisms from Psych Call:<br /><br />1. The "urgency" of the patient in the emergency room is indirectly correlated with how late it is.<br /><br />2. If you get angry and yell at me for being "racist" because I won't admit you to the hospital, it isn't going to make me relent--it's going to make me call security to escort you from the ER.<br /><br />3. The potential dangerousness of the patient is indirectly correlated to the likelihood that the nurses will actually have changed him/her out of their street clothes, put them in a gown, and removed their belongings from the room. We've seen bottles of alcohol and sometimes weapons.<br /><br />4. If you come to the ER with a wussy overdose attempt, like, taking a couple extra antipsychotic or antidepressant pills (barely over the therapeutic limit, and not a drug like lithium or a tricyclic), it is entirely possible that the ER doc will have the nurse place an NG tube and do a gastric lavage. No, I will not pull it out of your nose for you. Actions --> consequences.<br /><br />5. The "urgency" of the patient in the emergency room is indirectly correlated to the likelihood they caught an ambulance to come to the ER. This holds true in most areas of medicine, not just psych.<br /><br />6. The corollary to #5: the urgency of the patient is entirely unrelated to whether the police brought them in. Sometimes the police bring in the really outraged, psychotic, agitated patients who were swinging an axe at traffic; sometimes the police bring in the chronically suicidal "I called 911 and said I wanted to kill myself and no it has nothing to do with how much wine I drank tonight".<br /><br />7. The lateness of the ER consult is directly correlated to my level of crankiness and indirectly correlated to my level of "give-a-shit"ness.<br /><br /><br />Sorry for the rant, but psych call is mentally stressful and involves dealing with a lot of manipulative people trying to angle their way into the hospital. I hope that venting like this will help me not burn out and be able to keep showing up for call. /crankinessTiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com4tag:blogger.com,1999:blog-17754833.post-12892539484925261752009-02-08T15:14:00.003-06:002009-02-08T15:30:49.527-06:00Paging EtiquetteRules for Paging Properly:<br /><br />1) If you are going to be allowed to page me incessantly, then you should be required to wear a pager so I can return the favor.<br /><br />2) If you page me, please wait 5-10 minutes for a response before paging back. Heaven forbid I be answering another page, seeing to an emergency, walking in a hallway without a phone, or sitting on the john. I am very conscientious about returning pages and really try hard not to make you wait, but sometimes it's unavoidable.<br /><br />3) Please attempt to coordinate your pages. Having 2 different nurses page me about the same patient within 30 seconds of each other (indeed, I received page #2 while I was on the phone with nurse #1) is a little annoying. Especially when said patient isn't actually dying of a heart attack or writhing in severe pain, but "just wanted to talk to the doctor."<br /><br />4) I know mistakes happen, but please attempt to look through the medications before paging me to say Ms. so-and-so needs a sleeping pill. If I stop what I'm doing and pull up the chart only to find Ambien in their list of meds, it's a little irritating.<br /><br />5) Blood pressure of 135/anything does not excite me and I do not need to be paged for this, unless it was 220/190 5 minutes ago (in which case, why are they on a psych floor?).<br /><br />6) The primary team arrives around 8 am M-F. I do not need to be paged at 7:20 (while I'm trying to check out and leave) for 2-day long sore throats or potassium of 3.2 drawn 4 days ago. I appreciate your incentive and that you are trying to help care for your patient, but it can wait.<br /><br />7) When possible, please page me to an extension you'll be easily reached at. If you page me and I call you right back, only to reach someone who puts me on hold "while I find out who paged you", I get a little irritated, especially when this happens frequently.<br /><br />8) Perhaps most importantly, when I call you back, please introduce yourself and state the patient's name clearly (perhaps even spell it) before rushing into the story of how the patient has an urgent foot rash. I have some hearing problems--not your fault--and I will have to interrupt your story to ask you to repeat the name, spell it, and wait while I access that patient's chart in the computer before you get going again. Also, if you have a non-American accent, it is going to be difficult for me to understand you over the phone, especially if you speak rapidly.<br /><br />9) On my end, I promise to keep trying to answer pages promptly, identifying myself clearly when I call back, being really nice (or at least non-snarky) when I answer, and trying to educate the people paging me about appropriate paging. (Hey, I said "trying", didn't I? Stop looking at me, swan!) I know I fail at this frequently, but I really do try, I swear. I don't like paging people only to get yelled at, so I don't want to be the person yelling.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com2tag:blogger.com,1999:blog-17754833.post-14552276738625969222009-01-26T21:04:00.003-06:002009-01-26T21:30:39.974-06:00True Story from the Psych UnitI'm taking psych call this month at a large hospital. Call duties include consults from the ER, consults from the med/surg floors (rare, since they're after hours or on weekends), "behavioral emergencies" throughout the hospital, and covering the inpatient psych unit, which houses 40-50 patients. I would just like to throw in there that my psych calls are nearly as stressful as my medicine float shifts--psych call is not easy.<br /><br />A couple of weeks ago, my urology elective experience suddenly and unexpectedly came in handy.<br /><br />(If you're squeamish, stop here.)<br /><br />I had just returned a page from the nurse in the emergency room and was hearing about a patient I had to see (the usual "super urgent" med refill type) when I received 2 pages in about 1 minute from the floor. GODDAMN, dude, I'm on the phone with the emergency room! I'm sorry, but people need to learn some pager etiquette!<br /><br />Ahem.<br /><br />I returned the page with a slightly snarky "Did someone page Dr. TS TWICE? Can I help you?"<br /><br />A slightly panicked male nurse answered "Yes, doctor, patient so-and-so has gotten his, ah, his penis caught in his zipper."<br /><br />WTF???<br /><br />"Uh, is it, uh, is it still stuck? Is it bleeding?" (I was stuttering and nearly speechless)<br /><br />He assured me that it was not bleeding, but was still stuck. Holy Christ! I called the ER and told them I had a medical emergency to deal with on the floor (at which point I was "reminded" that there's a policy to see ER patients within 20 minutes of arrival--Eff You, guidelines! The nurse actually asked me why the floor nurses couldn't just "deal with it" themselves. Um, it's not YOUR junk caught in a zipper, but if it were I doubt you could wait an hour while I deal with Ms. "I didn't know how to operate the automatic refill telephone number"). I raced upstairs.<br /><br />The patient was lying on his bed so calmly I didn't realize it was the right man, until I saw his fly hanging open. It seemed to be an accidental injury (although I'm sure weirder things have happened). I donned gloves and did a quick inspection--whoo-ee, that skin was really wrapped in the zipper. (I warned you about the squeamish thing!) I left the room and paged urology.<br /><br />"Um, hi, this is the psych intern. I have a patient with his penis caught in his zipper. What do I do?"<br /><br />Uro: "You pull."<br /><br />WTF??? ARE YOU KIDDING ME???<br /><br />He wasn't kidding. I went in and attempted to pull on the zipper, but the patient freaked out (naturally) and wasn't going to tolerate it. I paged urology back and explained the situation.<br /><br />Uro: "I can come up there if you want, but I'm just going to pull harder."<br /><br />WTF???????????????<br /><br />The nurse on duty wouldn't let me take the patient down to the emergency room, since "this is a hospital up here, there's no reason a patient can't get treatment up here just like anywhere else." I had no choice. I asked for a bottle of lidocaine, a syringe, and some wound dressing materials. We got the patient into the treatment room, I did a little local anesthesia, gave him a Vicodin, donned my gloves again, and PULLED.<br /><br />It didn't budge (but at least this time the patient didn't feel a thing).<br /><br />We found a suture removal kit with a pair of forceps, which I used to try to get a grip on the zipper. This time when I pulled, it moved a teensy bit. I had the male nurse try to pull, I tried to pull, but we made almost no headway. I carry trauma shears in my pocket (you never know when these bad boys will come in handy) so we tried cutting the zipper off the pants and then cutting the zipper in half. Now, we were left with even worse leverage. I was beginning to freak out, thinking OMG WTF I JUST RUINED THIS MAN'S PENIS!<br /><br />The patient started talking to us at that point. He said he'd had this problem before (WTF???) and had seen a doctor with similar complaints before. He then reached down, grabbed hold of the zipper, PULLED, and the zipper broke in half; he PULLED again and it came off his skin. I nearly fell over with shock, amazement, relief, and nausea; the male nurse had turned around and was unable to watch.<br /><br />True, he had several lacerations that I cleaned with iodine and dressed with ointment. I put him on some antibiotics (his hygiene wasn't so great, and god only knows what was on that zipper), and we found him some sweatpants and some briefs. I also lectured the patient on a) wearing underwear and b) tucking it back while zipping up his pants. Honest to god, this was a grown man. I actually told him "Dude, you only have one of these, TAKE BETTER CARE OF IT."<br /><br />One of the highlights of the evening: I wrote an order in the chart to this effect: "Patient to wear briefs and non-zippered pants while injury heals."<br /><br />Not exactly what I had in mind when I signed up for this (but certainly a great story!)Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com4tag:blogger.com,1999:blog-17754833.post-18531867950052105212009-01-24T15:25:00.003-06:002009-01-24T15:36:36.402-06:00He's Fantastic (As Usual)If you have a few minutes and want to read about the history of nationalized medicine in England, France, and Switzerland, as well as the history of how the American health care system came to be, and even the American telephone system(?!), go read <a href="http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande?currentPage=all">this article</a> by Atul Gawande in The New Yorker. Go, now.<br /><span style="font-size:78%;"><br />I found the link at <a href="http://www.kevinmd.com/blog/">Kevin, MD</a>. Congrats on Best Medical Blog of the Year!</span>Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com5tag:blogger.com,1999:blog-17754833.post-61184634877608910962009-01-23T14:20:00.002-06:002009-01-23T15:24:37.485-06:00Evidence-Based MedicineI've long admired the attendings who really know EBM. I have aspirations to be one someday: have an office filled with articles to print out for residents, know which trial said what, who conducted the important trials, be able to read articles critically and pick up on subtle clues that the research was or wasn't great.<br /><br />I initially said "always" instead of "long" in that first sentence, but I changed it. My first experiences with EBM were pretty pointless. In our first year of med school, we took a mini-class in statistics, where we had to memorize the "ABCD" tables and what sensitivity/specificity meant. It didn't make much sense to any of us, and everyone groused through the course. That summer, I had to do a project for my preceptorship that involved "PICO" questions. They're ridiculously easy to write, so I couldn't figure out why I had to do so many. I was told that I needed to learn how to search Pubmed properly, so I had to have a good question. Later, I had more lectures on how to search Pubmed well. Seriously, people, most med students now are pretty familiar with Google or other search engines and know how to conduct a quick internet-based search to get what they want. Sitting through stifling lectures about "boolean operators" and learning the difference between searching with AND and with OR... Shoot me.<br /><br />I think med students may get turned off by the statistics and the uselessness of learning how to search the internet and lose sight of why EBM overall actually matters. It has very little to do with PICO questions, after all.<br /><br />The way I see it, EBM has several points. First, doctors should know how to critically appraise an article, so when the drug rep hands you the article about linezolid vs vancomycin you aren't blindsided by the pretty graphics. Second, doctors should know how to search the literature to find answers to clinical questions--this is where PICO comes in, but it isn't always necessary to go through that whole process. Still, if you want to read the actual study that UpToDate based their guidelines on, you should have an idea of where to find it. Third, all of this critical appraisal *should* lead to evidence-based guidelines for treatment. I know many doctors get upset at the idea of "cookbook medicine", but I'm all for some standardization (with final discretion always with the doctor and the patient, of course). If the literature said Drug X is very good in diabetes, but not Drug Y, then I think a doctor who wants to prescribe Drug Y to a diabetic should have a really good reason for doing so.<br /><br />So what are the downsides to EBM? Why isn't everyone doing it? I think there are several potential problems:<br /><br />First, while the randomized controlled trial is the gold standard for testing therapies (new drugs, new imaging, new surgical techniques &amp; devices, etc), not everything can feasibly have an RCT. Pregnant women and children are often overlooked for studies, because who wants to have their fetus or small child experimented upon? The elderly are often excluded from studies, as are the really ill patients. Thus, RCT's often ignore whole populations that may need a treatment, so then we have to try to extrapolate the results to an untested population (or, if you're a purist, just say "there's no evidence for X in pregnant women" and don't treat). Diseases with very small numbers of patients may be studied in fantastic trials that can't reach statistical significance due to lack of power. And sometimes, you just can't randomize people to have a certain condition--see the satirical "<a href="http://www.bmj.com/cgi/content/abstract/327/7429/1459?ijkey=425457f110f8db584617b87a1eace92eaa39ff02">Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials</a>" from the BMJ.<br /><br />Second, there's often a disconnect between study data and clinical practice guidelines. You don't usually base guidelines on the results of one study, but sometimes that happens--see the <a href="http://en.wikipedia.org/wiki/Women%27s_Health_Initiative">WHI</a> hoopla. A treatment may become standard of care based on one study (like using steroids for spinal cord injury) and then even when later studies debunk it you can't change the standard of care (<a href="http://www.epmonthly.com/whitecoat/2009/01/defensive-medicine-at-work/">defensive medicine</a>, anyone?). Other times, it takes years and multiple studies to "prove" something works or doesn't work, meaning at any given time the guideliness available are many years behind the evidence. Also, guidelines are written by "panels of experts", so sometimes it's difficult to tell what's truly EBM and what's "expert opinion".<br /><br />Which brings me to my third problem: we in medicine haven't done a good job of selling the public on EBM. Patients don't really know about sensitivity and specificity, false positives and false negatives, statistical likelihood of disease, number needed to treat, etc. How many people would take Lipitor if they knew that <a href="http://pharmamkting.blogspot.com/2008/01/statin-lottery-number-needed-to-treat.html">between 100-250 people</a> have to take it to prevent one MI? How many people would clamor for increased HIV testing in the ER if they were the patient with the false positive who had to go through the extra testing and fear of having HIV? Even worse, one may <a href="http://overlawyered.com/2004/08/update-commentary-on-merenstein-lawsuit/">still be sued successfully</a> for following EBM practices when it results in a poor outcome.<br /><br />Fourth, there's a wide disparity of practices between patients with money and good insurance and patients who do not, or even between geographic areas. In a rural area, if you have stable angina, you're likely to get nitro; in an urban area, you're likely to get a cath. Do people in urban areas live longer? (I don't know, but I haven't seen the evidence). I feel like one goal of EBM *should* be to reduce some of these types of disparities, but it hasn't really happened. The growth of medical technology outpaces the body of literature.<br /><br />Finally, what do we do when there is no evidence? Many of us are not comfortable doing nothing, and many patients are not comfortable doing nothing. For example, when a patient has viral bronchitis, we know the evidence says DO NOT GIVE ANTIBIOTICS. Yet, patients still come to the doctor with cough and runny nose. There's no evidence for giving<a href="http://content.nejm.org/cgi/content/full/355/20/2125"> cough syrup or inhalers</a>, yet I think many of us do so, simply for the sake of doing something (and to get the patient off our backs about the freaking antibiotics, the answer was NO).<br /><br />So why do I heart EBM? I feel that it's the best system out there for keeping abreast of the unbelievable amount of medical knowledge available. Sure, it's got flaws, and perhaps in the future a new system will come along and wipe EBM off the map, but until then we should use what we have.<br /><br />You can wake up now, I'm done.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com1tag:blogger.com,1999:blog-17754833.post-24755496665102958762009-01-19T21:25:00.003-06:002009-01-21T16:12:44.619-06:00Another New DSM-V Diagnosis<div class="gmail_quote"> <div><strong>Pager PTSD</strong></div> <div> </div> <div>Criteria for diagnosis:</div> <div>1) Exposure to a constantly blaring pager; correlation has been found between an increased number of re-pages within 3 minutes (because the person wearing the pager was in a hallway with no phones, so the person paging felt the need to "try again") and severity of symptoms</div> <div>2) Persistent reexperience; patient may have illusions of the pager going off or nightmares of missing pages</div> <div>3) Persistent avoidance of stimuli associated with the pager trauma, ie, turning the pager off when not on call</div> <div>4) Persistent symptoms of increased arousal, ie, sleeping with the call room light on so as not to sleep through a page, anger and cursing when the pager goes off, constant checking and rechecking of the pager when it is NOT going off to be sure the battery is intact</div> <div>5) Duration of symptoms lasts longer than the exposure to the pager; patient may experience resurgence in anxiety when other people's pagers go off or may fumble for an imaginary pager when hearing the sound of another's pager</div> <div>6) Significant impairment in occupational functioning such as cursing in front of patients when the pager goes off, snapping at auxiliary staff for paging incessantly, crying at work</div> <div> </div> <div> </div> <div>Often comorbid with or must be differentiated from the following potential new DSM-V diagnoses:</div> <div> </div> <div>1) Pager phobia--avoidance of pagers with increase in anxiety when the patient sees or hears a pager, reluctance to touch or wear a pager, patient must know symptoms are excessive</div> <div> </div> <div>2) Pager OCD--compulsions of constant checking and rechecking of the battery; patient may even test-page him or herself to rest assured that the pager is working; obsessive thoughts of the pager not working or of beating it to a pulp Office Space style<br /><br /></div> <div>3) Generalized call anxiety--anxiety and worries not just about the pager, but about the 40+ patients the intern on call is responsible for, interferes with sleep and appetite on call, patient may experience fatigue and muscle tension associated with call room bed and overweighted white coat pockets</div> </div>Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com5tag:blogger.com,1999:blog-17754833.post-23989361834735341082009-01-12T06:39:00.003-06:002009-01-12T06:58:34.589-06:00Loaded StatementThis dude gave a quote for a <a href="http://www.cnn.com/2009/HEALTH/01/09/who.still.smokes/index.html">smoking-related article</a> on CNN that I think is a) dumb and b) illustrates a point about paying for healthcare.<br /><p> </p><blockquote><p> Retired radio broadcaster and iReporter Gerald Dimmitt, 65, has smoked since he was 14. </p> "I've always smoked a pipe," he said. "I have successfully quit about 40 times." But, he says, he always restarted, because "it calms me down."<p>Dimmitt has even more incentive to quit now, since developing lesions and irritation in his mouth. After speaking to his doctor, he received a prescription for <a href="http://topics.cnn.com/topics/Chantix" class="cnnInlineTopic">Chantix</a>, a pill to aid with smoking cessation. But when he went to pick up his prescription at the pharmacy, he was charged $139 (because it's not generic) for two weeks worth. Outraged, he left the Chantix behind. </p><p> "If smoking is so dangerous ... why then do they want to charge $139 to make me stop? There is something very wrong with that. I guess they would rather pay to take care of lung cancer," he said.</p></blockquote><p></p>So, $139 is too much to pay to quit smoking (when apparently everything else this guy has tried has failed)--fine. But to imply that "they" would rather pay for lung cancer... when the treatment would involve some combination of surgery, radiation, and/or chemotherapy, along with hospital stays, and medication, and would cost THOUSANDS of dollars, that makes $139 seem more like a bargain. Essentially, this guy is saying that $139 out of his pocket is intolerable, so he'd rather make his insurance/Medicare/Medicaid (or whatever health coverage he has) pay for lung cancer instead--because clearly, if $139 is too much for this guy, then thousands is beyond his reach.<br /><br />I'm largely a supporter of some form of universal health care (although not single-payer), but I'm still torn on some issues, and this is one of them. This guy is going to deliberately forego a treatment that could help him stop smoking and save himself and his health insurance (or Medicare/Medicaid, I don't know what he has) thousands of dollars because he doesn't want to pay out of pocket. Essentially, his insurer is now going to pay for his poor judgment that he's acknowledging publicly on CNN.com.<br /><br />Now, is the answer to subsidize anti-smoking therapy? Maybe that's not a bad idea, if we're going to suggest banning smoking on federal property and such--use penalties on one side and rewards on the other, give a little extra incentive. Is the answer to penalize such people who are deliberately NOT trying treatment which may be effective in quitting who are deliberately placing an extra burden on the health care system? Maybe--in the private insurance world, these people may already pay a higher deductible, and I'm okay with that. I think that even with a universal health plan, people should be required to pay for part of their health care. ER visits should cost money. Prescriptions should cost money, especially brand-new brand-name meds like Chantix (although I'll admit, $139 for 2 weeks does seem steep).<br /><br />I just hope his insurer read his little "comment". I guess it's less "dumb" than I initially thought, because if his insurer will pay for his lung cancer why should he pay to quit smoking? Oh, I don't know, unless he'd like to LIVE without CANCER. Because lung cancer kills you. People (myself included) need to take some freaking responsibility with their own health.<br /><br />Now I'm all riled up to start my Monday. Grrr.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com5tag:blogger.com,1999:blog-17754833.post-88492972146159260992009-01-09T14:56:00.004-06:002009-01-09T16:05:09.812-06:00You Need to Be in the HospitalI'm learning the ropes in psychiatry, and one issue that comes up is "commitment". Why is it that you can "commit" a patient to the hospital for their schizophrenia, but not for their myocardial infarction? What is the difference? How are the procedures different for each? What if the patient wants to leave AMA? I think there's a lot of fear and misinformation surrounding this topic, so I'd like to delve briefly into how a medical hospital stay is similar to and different from a psychiatric hospital stay.<br /><br />If Mr. X walks into the emergency room with chief complaint of "chest pain", he gets triaged to the medical ER. Likely within a few minutes he'll have an EKG and cardiac enzymes done. If the EKG shows massive ST elevation and the troponin is elevated, the doctor will say "Mr. X, you are having a heart attack. You need to come stay in the hospital to have treatment."<br /><br />Mr. X has two options at that point: say "sure doc" or "no way". If he says yes, he signs the consent form and is off to the cath lab. If he says "no way", it's a little more complicated. Is he delirious? Is he drunk? In other words, is he in his right mind and able to make this decision? Is he unconscious without family around--if so, you treat emergently and let the consent work itself out later. If he is not delirious, you assess him for capacity to refuse treatment: does he know what a heart attack is, does he know what the treatment is, does he know he could die without treatment, does he know he could live with the treatment? If he meets capacity and says "doc, I know I could die if I leave, but I do not want treatment" then he signs a paper stating that he is leaving Against Medical Advice (AMA) and walks out the door. The procedure is the same if he's already on the floor and decides to leave.<br /><br />What if Mr. X is delirious? What if his brain is deoxygenated and he's agitated and trying to leave, but only yesterday he told his wife "absolutely treat me if I have a heart attack?" In this situation, you can obtain consent from his wife (or next of kin) for treatment and pursue treatment. If you document that the patient does not have the capacity to refuse, and you feel that the benefits of treatment likely outweigh the risks, and that they are "not themselves" (disoriented, delirious, etc), then you now have the ability to use restraints against this patient if you need to do so. Ever see the patients tied down in the ICU so they won't pull out the vent tube? A patient who is septic, hypotensive, and delirious may try to pull out a tube--they're uncomfortable--and clearly doesn't know that what they're doing can kill them. That patient is at that moment being held and treated against their will, so this is not something you take lightly. Restraints usually have to be assessed every few hours by a doctor, and patients may need to be sedated so they don't a) have discomfort that led them to try to pull the tube out in the first place and b) fight against the restraints so hard they have rhabdomyolysis.<br /><br />Therefore, not everyone in the medical hospital is there with their consent. An adult with capacity may consent to or refuse treatment and this should be honored. An adult without capacity to consent to or refuse life-saving treatment may be restrained in certain situations. The family may provide consent for treatment if the patient is incapacitated (which is how we end up with so many demented patients in the ICU--another issue altogether).<br /><br />So how is it different in psychiatry?<br /><br />If Mr. Y walks into the same emergency room with chief complaint of "I want to kill myself", he gets triaged to the psychiatric ER. Shortly thereafter a doctor or "mental health professional" (maybe social worker or PA) will assess the patient and perform a mental status exam. If the patient is very depressed, still says he will kill himself, and states that he keeps a loaded gun at home just for this purpose, the doctor will say "Mr. Y, I'm concerned for your safety. You need to come stay in the hospital to have treatment."<br /><br />Mr. Y has two options at that point: say "sure doc" or "no way". If he says "sure doc" then he signs a consent for mental health treatment and is admitted to the psych unit (after some basic labs to be sure there's nothing major medically wrong at that moment). If he says "no way", then it gets tougher. If his risk of committing suicide seems very high, as in he is an elderly Caucasian male, feels hopeless, has no family, lives alone, has a firm plan for death, is in dire financial straits, and it's the anniversary of his wife's death, then you may make the argument that he is in imminent danger of harming himself and should be admitted to the hospital. (If his risk is low, he's a "frequent flyer" in the ER who uses this line to get a warm bed because the shelter was full and his check is spent, etc, then "Sayonara!") You may also argue that the patient's severe depression is preventing him from making rational decisions or having full capacity to refuse treatment.<br /><br />For psychiatry, instead of having the family sign the patient in when they refuse but lack capacity, you file paperwork with the court--legal "commitment". This varies from state to state, but usually involves some manner of stating that the patient is in imminent danger of harming himself or others, lacks capacity to refuse due to mental illness, and will acutely decompensate and/or likely kill himself if allowed to leave without treatment. The patient will be brought to a locked psych unit and will remain until treatment is completed. Patients who are on "involuntary" status don't necessarily stay longer than "voluntary" patients; it simply means that they must stay until a physician releases them or the court determines that they may be released.<br /><br />Now, if Mr. Y signs himself in voluntarily, but 4 hours later decides he wants to leave, what do you do? On the medical floor, the patient asks to sign out AMA. In the psych unit, they ask for essentially the same thing. Different states have a different procedure for doing this, but the patient must ask for a document stating that they want to leave (essentially AMA). A doctor must come examine them within a certain period of time to determine whether the patient has capacity to leave. Mr. Y in our example above told us 4 hours ago he wanted to kill himself and has a gun. If the doctor examines him and he says "doc, I want to leave so I can go kill myself", then the doctor is going to have to file paperwork to commit him to the hospital--after he's already there. If the patient is stable, and doesn't meet criteria for legal commitment, then you must let them leave AMA after they request it.<br /><br />We often err on the side of having patients sign in voluntarily so that the patient isn't forced to be committed legally, but sometimes that leads to a double standard (in my opinion)--we're saying the patient has capacity to accept treatment (which we want), but not to refuse (which we don't want). I think one reason we do this is because we want to use the commitment process as infrequently as possible. Once a patient has been committed, this becomes a matter of public record with the court, where if they sign in voluntarily this is covered by HIPAA.<br /><br />Legally, it's all very complicated. Due to some abuse of commitment in the past (in this country and others) a very complicated set of rules must be followed. The patient must meet criteria for admission (usually reserved for acutely suicidal, acutely psychotic, acutely manic, etc) and be either about to commit suicide, about to hurt someone, or be completely unable to take care of themselves (the manic patient wearing their undies in the snow to preach the gospel in the middle of the street, for example) to the point that they cannot practice basic safety. Once you file paperwork with the court stating that you've examined them and they should be committed, they'll be assigned a court date. After around 72 hours, a second exam must continue to document that patient still requires involuntary hospitalization. The case will go before a judge at some point who will either confirm the commitment until a doctor says they may be released or will deny the commitment and order the release of the patient.<br /><br />You can also order emergency medication. After his heart attack, Mr. X became hypotensive and was acutely bleeding, and was unconscious so he couldn't sign the consent for blood products; he will still be transfused. After his admission, Mr. Y became acutely psychotic and agitated, tried to throw tables at the staff, tried to punch through a glass window, and refused to take his meds; if he refused to take an oral med, he would likely get a shot of something sedating (usually haldol 5 mg + Ativan 2 mg) to calm him down. If Mr. Y continues to refuse to take his meds, continues to be agitated and dangerous, you can petition the court to order medication.<br /><br />Some people would argue that the two aren't the same at all. After all, the patient with the MI who is bleeding is going to die; as my med student put it yesterday "well, psych stuff isn't life-threatening." It depends. Even patients in locked psych units can commit suicide if they're determined enough; they can commit homicide, they can attack other patients or staff. A condition called "<a href="http://www.acep.org/ACEPmembership.aspx?id=31850">agitated delirium</a>" or "excited delirium" can actually cause a patient who is so overstimulated by their psychosis (and often by drugs) to suddenly drop dead. Maybe it's not as clear cut as the MI situation, but psychiatric patients can die from their disorders or related complications. Speaking for myself and the people I work with, we wouldn't put someone in the hospital against their will and medicate them against their will if it didn't seem vitally important to that patient's ability to survive.<br /><br />Legal commitment remains controversial; just look at the <a href="http://en.wikipedia.org/wiki/Involuntary_commitment">wikipedia</a> page. Obviously, there is some overlap with this and medical treatment, but some striking differences as well. I think we should continue to work very hard only to use involuntary hospitalization and forced medication when absolutely necessary. Judicial oversight helps keep the process honest, but I'm sure mistakes are made. It does help to compare it to what happens in the regular hospital; if you're out of your right mind and lack capacity you're not leaving, whether it's post-MI or the aliens infiltrating the TV set. If you need emergency IV fluids or emergency sedation, it's an emergency, period. This is a rather awesome power doctors wield, and I'm kinda glad there's a judge looking over this process.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.comtag:blogger.com,1999:blog-17754833.post-33345528545353370102009-01-04T21:43:00.002-06:002009-01-04T21:47:49.824-06:00First Post of the New YearAnd it's a lame one. I've been busy, blah blah blah, vacation/work/learning psych call. All the same old excuses, and largely the same ones I use when I don't go to the gym. Hmm, methinks I need some new excuses! (Or I need to get my fat butt to the gym--I gained at least 5lb on that cruise, but at least the food was amazing!)<br /><br />Happy New Year to you and yours!<br /><br />And for the love of god, if it's not too late, try not to take your first disability check of the year and go celebrate by snorting/shooting up/smoking >$100 of cocaine. Try to pace yourself, or you're going to end up in a psych ER seeing and hearing Satan telling you to kill yourself, and that's just not pleasant.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com1tag:blogger.com,1999:blog-17754833.post-65259213291180678522008-12-22T19:30:00.002-06:002008-12-22T19:55:21.525-06:00God-AwfulMy husband was talking to a non-medical friend at a party the other night, and he referred to internship as being "god-awful." I immediately turned to him and corrected him.<br /><br />I do not think internship is god-awful.<br /><br />In fact, I have been fairly happy lately.<br /><br />Yes, I have been really stressed out. I have cussed out loud while getting gang-paged and dropping the call pager into a cup of coffee. I have been (unintentionally) surly to nurses who have paged me for 2 am constipation. I have had months where I've been very sleep deprived and cranky. My house is filthy. I almost never cook dinner. I've put weight back on because I am often too tired or busy to go to the gym. Sometimes I snap at my husband out of stress and anxiety.<br /><br />It's also true that I've been to 2 excellent rock concerts and 1 symphony concert since starting residency. I've gone to visit my sister. I've made friends with some of my neighbors, who are awesome people (and closed my garage door for me last night, since I left it open by accident). I've kept up with friends nearby and seen 2 friends who moved cross-country for residency. I've read a few non-medical books and played a lot of Rock Band (II was my birthday present!) Thus far, I've kept up my blog, and my reading of multiple blogs (thank you, Google Reader!). We put up our tiny Christmas tree and some really puny Christmas lights, which somehow makes me really happy. My husband remains incredibly supportive through all of this and still spoils me rotten.<br /><br />In residency, I've almost finished 6 months at several different hospitals, some inpatient, some outpatient. I've taken some call and learned a ton. I've learned a lot about teaching med students and giving on-the-spot feedback (although I'm definitely still a beginner). I found out I really liked internal medicine as a resident, which surprised me (I really didn't like it as a student). In fact, I liked IM so much, I have concerns about how much I'll like psych when I start in January. I'm studying for Step 3 and it's astonishing how much I've learned, how much I've forgotten, and just how much there is that I've never learned about.<br /><br />Now obviously, I'm not a general surgery intern, or even a medicine intern. Psych internship is relatively cush compared to what many interns endure. I could imagine that other interns are way less happy. Overall, though, when I look at my current lot in life, I'm pretty satisfied, and look forward to where this is all going. So no, residency is not god-awful.<br /><br />And now, Merry Christmas (or whatever holiday you celebrate)!Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com2tag:blogger.com,1999:blog-17754833.post-58371133432269010052008-12-20T20:20:00.002-06:002008-12-20T20:45:44.843-06:00Public PersonaThere is a post over at <a href="http://psychiatrist-blog.blogspot.com/">Shrink Rap</a> this week regarding an article in the <a href="http://www.psychiatrictimes.com/home">Psychiatric Times</a>, written by a psychiatry resident. The article got posted to several weblogs, and suddenly the author's email address ended up posted in the comments section. Now, you have an article that was written for an audience of psychiatrists, therapists, and other health care professionals. I really doubt that the author intended for this article to get posted to the internet for all the world to read.<br /><br />The problem is, now this article is out there. The article featured the author's name and school affiliation. While I'm sure she changed some identifying characteristics, there's still a potentially recognizable patient in this article. As someone pointed out to me, if this patient felt the urge to Google his former therapist's name (which is not uncommon--who hasn't Googled themselves? Um, I mean, not me) then he'd find this article very easily. Chances are, this patient may identify himself in this article, especially since the therapist's name is attached. It's unclear from the article whether the patient gave his permission to have his story used in this manner, but given the tone of the article it seems unlikely.<br /><br />How is this better than an anonymous blog with patient identification removed and characteristics changed?<br /><br />Yet, some residencies will allow, even encourage their residents to publish in magazines and journals like Psychiatric Times, yet have policies forbidding residents to write blogs or post to message boards. I feel that policies regarding internet writing should be more reasonable and take into account the level of anonymity of the blog. It's one thing to post publicly "I'm a resident at XX school and my name is YY and I worked 95 hours last week and I think this affected my patient outcomes"--which seems to be what residency programs are afraid of, and what lawyers may look for in litigation. It's entirely another to post anonymously, take careful precautions with patient identification, and be deliberately vague.<br /><br />One argument I could foresee regarding the difference in regulation is that an article in a journal or industry magazine is published with the intent to educate, whereas a blog post may be more for entertainment. I disagree, however--I rely on multiple blogs to help with my every day medical education. I know much more about recent Medicare legislation, new medical studies, and interactions between drug companies and medicine because of reading blogs than I do from my standard education. I receive 3-4 journals a week at my house, and I quickly get overwhelmed trying to read them all. Reading small amounts of blog posts daily, however, is much more feasible, and usually feature links to the actual articles so I can read them for myself.<br /><br />Publishing case studies is a long-honored tradition in medicine. New diseases and therapies come to attention through case studies--reports of one or a few patients with a given syndrome or receiving a specific treatment. I do not have a problem with the article in Psych Times; in fact I found it enlightening. I simply feel that blog writing should be given the same consideration, given the crossover between internet publication and traditional academic journal.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com1tag:blogger.com,1999:blog-17754833.post-12763039714510683672008-12-14T19:56:00.003-06:002008-12-14T21:11:12.370-06:00Anxiety = Psychosis*That seems wrong, doesn't it? There are plenty of patients who have generalized anxiety disorder who are not psychotic. In fact, I'm not really sure how you'd give someone a diagnosis of schizophrenia and GAD concurrently. To AstraZeneca, however, this difference doesn't matter. They'd like you to give your patients with generalized anxiety disorder an antipsychotic every day, preferably for the rest of their lives.<br /><br />Confused yet? Don't believe me?<br /><br />November 2008's <span style="font-style: italic;">American Psychiatry News</span> published an article titled "Study: Quetiapine Monotherapy Works for Generalized Anxiety Disorder" (Vol 1 No 11, p22). The authors discuss data presented on a poster at the meeting of the Anxiety Disorders Association of America, funded, of course, by AstraZeneca, makers of Seroquel XR. The study randomized 234 patients with GAD to receive 50 mg, 150 mg, or 300 mg of extended-release quetiapine versus placebo. The meds were taken for 8 weeks with a 2 week discontinuation taper at the end.<br /><br />Hamilton Anxiety Rating Scale (HAM-A) scores were used to determine the rate of improvement. Since this isn't the full study, I don't know exactly how anxious the patients were to begin with; <a href="http://imaging.cmpmedica.com/CME/pt/PDF/HAMA_Instructs.pdf">this website</a> uses 14-17 for mild symptoms, 18-24 for moderate symptoms, and 25-30 for severe symptoms. The study found that placebo-treated patients improved a mean of 11.1 HAM-A points; 50 mg Seroquel XR patients improved 13.3 points; 150 mg patients improved 13.5 points; and 300 mg patients improved 11.9 points. The 50 mg and 150 mg doses' improvement was statistically significant, p<0.001.><blockquote>"The most common adverse events were dry mouth, somnolence, sedation, dizziness, headache and fatigue. During the treatment phase, 15.9% of the patients taking quetiapine XR 50 mg per day withdrew as a result of adverse events, as did 18.1%, 24.4% and 6.4% of those receiving quetiapine XR 150 mg per day, quetiapine XR 300 mg per day and placebo, respectively."</blockquote>So, the patients taking 50 mg of Seroquel XR improved by 2 extra points on a rating scale, but were 2.5 times as likely to withdraw from the study because they felt the side effects were too severe. That's important here. These patients are saying the improvement in their anxiety was NOT as significant as the addition of the side effects of the medication, given how many of them discontinued the medication.<br /><br />In the US, you only need to show that your medication is better than a placebo to get FDA approval. Let's ignore the fact that there are multiple good treatments for generalized anxiety disorder, from SSRI's to buspirone to long-acting benzodiazepines to non-pharmacologic therapies like CBT. Let's ignore the fact that AZ is trying to win the approval <a href="http://www.reuters.com/article/healthNews/idUSTRE49K1YS20081021">specifically for Seroquel XR</a>, so if you use plain old Seroquel (expensive enough in its own right) for GAD you'll be using it off-label. Naturally, the drug reps will emphasize the long action and smoothness of XR versus regular (never mind that for most indications, Seroquel can be dosed once daily, which is usually the benefit to using a long-acting form). According to <a href="http://en.wikipedia.org/wiki/Quetiapine">Wikipedia</a>, the Seroquel patent will expire in 2011 in the US, but the XR patent goes until 2017. XR = $$$$$.<br /><br />*I played a little loose here. The doses of Seroquel XR used in the study were not actually antipsychotic doses (except the 300 mg dose, which was no better than placebo). At 50 and 150 mg doses, you're getting a whole lot of anti-H1, or antihistaminic, effect; some antimuscarinic effect (hence the dry mouth), and probably some anti-serotonergic effect (which likely gives it mood stabilizing properties). No anti-dopaminergic effect. So, using 50 mg Seroquel XR is more akin to using an SSRI + Benadryl than to using Haldol. It's just a LOT more expensive than SSRI + Benadryl. Naturally, we don't have any data to show how Seroquel XR compares to any of our other therapies for GAD, but AZ doesn't have to ascertain this, so they won't. And economically, they shouldn't, if they want to sell shitloads of Seroquel XR.<br /><br />This is the kind of thing that drives me crazy about psychiatry, medicine, drug companies, etc. There's nothing inherently bad about Seroquel XR; there's nothing wrong with AstraZeneca trying to make money; there's nothing wrong with the article as published, per se. It's just the whole thing put together feels like a huge scam. "Statistically significant" doesn't necessarily mean anything, especially when the <span style="font-style: italic;">clinical</span> effect is small and the side effects were so bothersome that within 2 months 15.9% and 18.1% of patients (at the effective doses) had quit taking the medicine. For those of you who may be in medical school, suffering through evidence-based medicine classes, wondering why in the world do you need to know this crap, THIS IS WHY. So you can be an informed prescriber and consumer of health care dollars and not just take the word of the local drug rep, or even the word of your "Clinical Psychiatrist's News Source".Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com2tag:blogger.com,1999:blog-17754833.post-8948178720194236812008-12-10T18:49:00.000-06:002008-12-10T18:49:00.642-06:00The 80 Hour Work WeekThis has been a hot point ever since it was introduced several years ago. Recently, it has come to the attention of several prominent bloggers; see <a href="http://www.medrants.com/index.php/archives/3977">here</a> or <a href="http://www.kevinmd.com/blog/2008/12/would-you-want-tired-doctor-who-knows.html">here</a> or even <a href="http://www.the-hospitalist.org/blogs/wachters_world/archive/2008/12/06/the-iom-and-resident-duty-hours-did-they-get-it-right.aspx">here</a>. It seems the recent hullabaloo came after the Institute of Medicine <a href="http://psnet.ahrq.gov/resource.aspx?resourceID=8815">released a report</a> on resident duty hours where they recommend decreasing the length of a shift even further, to 16 hours, with more naps, at an estimated cost of $1.7 billion to hire the additional staff necessary to make up the gaps in coverage. All of the above links give excellent, thorough analysis of the situation, including some of the history of the 80-hour work week idea, so I won't repeat it.<br /><br />As a med student, I didn't log or keep track of my duty hours in any way. I'm reasonably sure that I worked around 80 hours a week on my medicine rotations, and possibly on surgery, but likely no more. I was gung-ho for the cap rules at that time. Many attendings who talked about it gave crappy reasons for hating the 80 hours, like "I went through it, so should you." I never heard a rational, reasoned argument against it in med school. I felt like, 80 hours sucks and is a lot, but it could be worse, so why not?<br /><br />Then I became an intern.<br /><br />One of my rotations in the past few months had a night float system for covering patients overnight when your team wasn't on call. It was a terrible system. Essentially, multiple teams would print out 1-page spreadsheets of their patients and then come "check out" to me, usually while I was trying to write notes or admit patients or otherwise do my work. These check out sheets had only the barest of information on them: name, MRN, age, 1-liner about their problem, code status, and anything specifically for me to check up on overnight. Stat electrolytes, stat PTT's for heparin drips, stat H&amp;H for GI bleeders--they'd give me a time, and I'd write down when I should check it. All in all, I estimate that I'd hold about 80 patients' worth of information in my hands by around 6 pm, including my own (the float shift would start after a full day call of admissions, so I'd still be working up my own patients and writing H&amp;P's while taking checkout and seeing float patients).<br /><br />Then the pages would start. "Mr. so and so is asking for pain meds." I'd go to the proper sheet, look him up, and voila! Absolutely no reason listed for him to have pain. I'd go into the EMR, look him up, no notes documenting pain but "he says he has bursitis in his shoulder and he really wants Vicodin." On principle, I'd try negotiating ("give him ibuprofen first") but usually ended up just writing for PRN Vicodin to save my sanity, as every time the pager would go off for Mr. Bursitis I'd die a little more inside.<br /><br />Then "Mrs. X's fingerstick reads 'Hi' and I rechecked it twice". Or "Mr. B is having a-fib and his heartrate is 150 and his blood pressure is 90/60." And so on, and so forth. Every time the pager went off, I'd shuffle through a huge stack of papers, trying to figure out who the F the nurse was asking about (and usually trying to decipher the accent), then I'd look them up and try to decide what the hell to do. I had a back-up resident who helped me with anything serious, but still. Being the main doctor overnight for so many patients, almost none of whom you know, is seriously frightening. The potential for error on my part, as I tried desperately to flick through the comptuter for 30 seconds while the nurse waited impatiently on the phone, was huge.<br /><br />Much has been made recently of the sleep vs handoffs argument. It is true that handoffs can increase the potential for error. I'm not sure if there are any studies that can truly say that handoffs increase the error MORE than working >80 hours (or longer than >30 in a shift)--if there were, the answer would be easy. I will say that after working my first of these night float shifts, I was much less cavalier about checking stuff out to the float. As float, I barely had time to go to the bathroom or examine my own patients, let alone check labs q 1 hour for other peoples' patients.<br /><br />Obviously, there are programs that have different (and probably better) ways of handling cross-cover. The Day Float resident is a great idea: someone who shows up during post-call rounds, learns all the patients, then stays into the afternoon to finish orders with the attending when the rest of the team leaves around noon. Having a limit to the number of patients allowed per resident on cross-cover might be okay, so long as you can put extra residents on the float shift. Big hospitals will have to have different solutions than small hospitals, where one resident could feasibly cover all of medicine or surgery overnight.<br /><br />Given the choice, when I desperately wanted to go home but I needed to see if Mr. Y had pneumonia or my patients needed morning labs or I needed to check the orders to see if everything was done, I chose every time to stay and do it myself. I'm not bragging about myself in this, because most residents do the same thing. When they slap "MD" on your coat and it suddenly grows a few feet in length, there's an enormous sense of responsibility that falls on you. Suddenly, these are YOUR patients. If something gets overlooked and the patient gets sick in the middle of the night, that's not the float's fault, it's yours. Yes, this is partly the over-exaggerated compulsion and perfectionism that is part of most doctors, but it's partly true. In my current system, no cross-cover will ever take as good of care of my patients as I do (and when I'm the cross-cover, I can't possibly do as well as that patient's team). Having someone hassling me about breaking duty hours just added to my stress. (And to be honest, it really hasn't been too much of an issue--I've gone over 30 just a couple of times, and never averaged more than 80, and have always had my 4 days off per month.)<br /><br />So, what I'm saying is, the 80 hour rule is kind of a pain in the ass. I agree that going back to q3 call with no restrictions on duty hours is medieval at best, and I'd hate to see that happen. I get tired enough working 70-80 hours per week. However, further restricting the hours without helping programs find manageable solutions to handoffs is not going to make it any better. Balancing patient and resident safety is paramount, and should not be mutually exclusive concerns.<br /><br />I'd like to make one seemingly tangential comment. I've heard a lot of whining that residents aren't going to noon conference because the 30 hour rule prohibits it. Actually, if you arrive at 7 am, 30 hours is up at 1 pm the next day. If you want residents to come to noon conference post-call, just decree that they are not allowed in the building before 7 am the preceding day. And then tell their attendings not to round for 6 hours post-call, so they can get their work done and make it TO the conference. Ideally, there would be food at this conference, which is my favorite motivator. This is not an impossible situation to solve, people.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com3tag:blogger.com,1999:blog-17754833.post-14569498400150971962008-12-09T17:16:00.003-06:002008-12-09T18:48:43.298-06:00What is Wrong with AmericaI'll admit to occasionally getting sucked into reality TV. I used to watch America's Next Top Model with some girlfriends religiously. I'm not really a fan, but I understand the appeal of mindless entertainment.<br /><br />Today, while at the gym, one of the TV's was tuned to "<a href="http://en.wikipedia.org/wiki/Real_Chance_of_Love">A Real Chance of Love</a>", a new reality dating show on VH1. Apparently, these two charming brothers who weren't classy enough for <a href="http://en.wikipedia.org/wiki/I_Love_New_York_%28TV_series%29">New York</a> were chosen for this show. Their names? "Real" and "Chance", hence the title of the show. (I must say, these were two of the most ghetto-ed out guys on TV). The episode I saw involved 7 of the women (who are largely split into "Real's girls" and "Chance's girls", but there seems to be some overlap) going to a club with the guys, only the guys get into a fight with a dude who has the nerve to hit on one of the (scantily-clad) ladies. The guys are "Pissed!" at this dude, so they talk smack, dude talks smack, dude pushes, brothers take him down. One of them hits dude on the head with a glass bottle. Girls are pushed out the door into their stretch limo by the producers. In the car on the ride home, they hold hands and pray to Jesus for their "boys".<br /><br />(It gets better)<br /><br />Upon arrival at their house, the police are waiting. They individually question the girls, on camera of course, as to what they saw. Who hit the dude with the glass bottle? they ask repeatedly. They threaten to make the girls accessories to murder if the guy dies. Some girls cry, some say "so and so did it" and then change their story, one girl flat out says "guy x did it". One girl says "I'm not talking to you" and walks out, and one girl says "I didn't see nuthin', they pushed us out the door." The guy who did the hitting is locked up in cuffs and dragged out.<br /><br />Surprise! His brother pops up and says it was all a joke, a challenge! The cops come back in and laugh, and dude walks in--he's fine. The brothers wanted a "Ride or Die" kind of girl (which is the title of the episode), the kind of girl who is loyal to the end and will never give up her man. The challenge winners? The one who just didn't say anything and the one who lied and said she didn't see nothing. The other girls were pissed. "I never talked to no cops before! I got no experience with police interrogation! It's not fair!" says one. The girl who told the truth to the cops is angry that they played with her emotions like that, and ends up getting booted off the show at the end of the episode.<br /><br />My brain almost imploded on itself.<br /><br />Not a single one of them mentioned anything about the truth or seemed to give a crap that (for all they knew) a guy was dying in the hospital. It's all well and good that the one chick simply refused to talk to the cops--that's her constitutional right. Any one of these girls could have said "I want a lawyer" and I'd have cheered them on. But for all the rest to straight up lie--if they'd been in a real police situation, that would have gotten them in far deeper trouble. After the fact, they were pissed because they'd never had the chance to lie to cops before, it was hard! The one girl who just told the truth was booted out of the house for not being loyal enough. And I just kept thinking, while watching them pray for their boys, that Jesus would want nothing to do with this situation. These ghetto guys, sitting around with their skanky women, got so mad that a guy dared to flirt with one of their ladies (and who would assume that 7 women all belong to 2 men?) that a fight ensued. Yes, it was all staged, but these girls believed it was all real, and they didn't find it weird!<br /><br />Truly, the next great health campaign, in the spirit of "Just Say No to Drugs" from Nancy Reagan, needs to be "Get Rid of Terrible 'Reality' TV". Either that, or I'm going to have to put a condom over the television to protect my eyeballs from that kind of syphilitic programming.Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com3tag:blogger.com,1999:blog-17754833.post-85696530020065194832008-12-02T19:17:00.002-06:002008-12-02T19:45:04.491-06:00Do Not Be WeirdThis advice goes out to all of you who may be interviewing for residency soon. I cannot stress enough, DO NOT BE WEIRD. Do not be weird at any point of the interview process, including the pre-interview dinner/social. At my program, I'm part of the recruitment committee, which means I go to a few of the pre-interview dinners and conduct informal lunch interviews from time to time. I didn't realize last year when I was interviewing that these dinners and lunches are all scrutinized. Let's put it this way: if you think they may be evaluating you, they probably are. And if they're not, you should behave as if they are anyway.<br /><br />My evaluations of candidates are certainly not the thing that makes or breaks them getting into our program. Rather, groups of evals are piled together to give an overall picture of a candidate. If one resident has an off eval but everyone else loves them, the off eval gets discarded. However, if several residents give off evals, this sends more of a message that this person may be a problem.<br /><br />Cases in point:<br /><br />1) Dinner started at 6. Applicant walks in at 6:40 (without calling to say they'd be late), surveys the group, asks "where's the pitcher of beer?", and proceeds to order one from the waiter without asking if anyone else is drinking or wants beer. Don't be an alcoholic at the dinner.<br /><br />2) At a dinner just prior to the election, an applicant walked in wearing a prominently displayed political button. You simply cannot assume that everyone will agree with you at your interview dinner, and is it worth not getting into a program because someone got offended at your button? (This is a trivial point, for sure, but to me this implies that this person will be so passionate about their politics that they may be difficult to speak to without lengthy political harangues--not that I know anybody like that...)<br /><br />3) Don't make fun of the male resident's choice of beverage by saying "That's so fruity". Do you know if they're gay? For that matter, do you know them at all? How can you possibly assume that person will not be offended by such a comment (unless you know them well)? (I wish I was making this up)<br /><br />4) Dinner started at 5, applicant walked in at 5:45, looked at all of us eating, and asked "Oh, did you all get here early?" Awww-kward!<br /><br />5) Don't spend the whole night talking about how amazing some other program is and how every other program in the country needs to adhere to the same standards as this other program and why doesn't your program do x like that program does?<br /><br />6) Don't wear a denim jacket covered in fringe. Nuff said.<br /><br />Actually, these comments were all made about 2 interviewees in some order. Any one of these things would have been okay by themselves--put together, they made most of us uncomfortable at the dinner, and several of us emailed the directors to say so.<br /><br />Other advice for your interview dinner or interview day:<br /><br />1) Again, DO NOT BE THE ALCOHOLIC. If people are having drinks, fine. If no one else is drinking and you want one drink, fine. If no one else is drinking and you order a pitcher, that's weird. This is psychiatry, we treat addiction all day--why advertise yours at the dinner? (although, maybe I should thank them for doing so)<br /><br />2) For your interview, you must have a nice suit. Colored suits or pinstripes are perfectly acceptable within reason--no white, purple, or pink suits, please. The goal of your interview suit is to look nice and blend in, basically. People don't often remember the amazing Chanel suit, but they do remember the girl wearing black stretch pants with a turtleneck, because she sticks out (not even kidding, except that was med school interviews).<br /><br />3) Tattoos and piercings: depends on the program and the specialty. My program has people who have both, including myself, but I didn't flaunt my tattoo during the interview (it's on my backside, so that would have been difficult). Some interviewers will take offense at dudes with earrings, dudes with long hair, people with pink hair, anyone with nasal piercings, etc. I know some people feel that their raging individualism makes it all worthwhile, and they'd rather die than go to a program where their neck tattoo isn't accepted, but again, I feel that the point of the interview day is to make your appearance NOT STICK OUT. They might remember you if you're amazingly hot, but they'll definitely remember large stretched ear piercings, etc. Why take a chance? Cover it up!<br /><br />Fortunately, the majority of candidates I've interviewed or met at dinner were very nice, and I don't hesitate to pass on that I think so. I'm sure I'll have more to report back after interview season is over, so stay tuned!Tiny Shrinkhttp://www.blogger.com/profile/14584375132138526435noreply@blogger.com11